Determinants of correct knowledge on tuberculosis transmission and self-reported tuberculosis prevalence among general population aged 15–49 years in Myanmar

Introduction Myanmar has been identified as one of the tuberculosis (TB) high-burden countries and having an understanding of TB transmission is vital for personal infection prevention as well as preventing transmission to others. This study aimed to identify the determinants of correct knowledge on TB transmission and self-reported TB prevalence among general population in Myanmar. Methods This is a cross-sectional study using secondary data from Myanmar demographic and health survey 2015–16. The determinants of correct knowledge on TB transmission mode and self-reported prevalence of TB were assessed using multivariable logistic regression models. Weighted estimates were provided in all analyses to account for the multistage sampling design used in the survey. Results Among the respondents, less than half (44.6%, 95% CI: 43.9, 45.4) had the overall correct knowledge about TB transmission and misconceptions. Older age group, female gender, those with higher education and higher socioeconomic status, and exposed to mass media at least once a week, residents from the delta and lowland region or plain areas were more likely to have correct knowledge about TB transmission. The overall prevalence rate of self-reported TB was 2.6% (95%CI: 2.4, 2.9) and the prevalence was higher among older age group and males. Conclusion Our study highlights the need for targeted efforts to improve awareness and understanding of TB transmission among general population in Myanmar. The study suggests the implementation of appropriate, innovative, and comprehensive targeted TB education and communication strategies.


Introduction
territory, seven states, and seven regions. Geographically, Myanmar has a diverse landscape, encompassing plains, coastal, delta, and hilly regions. The population of Myanmar exceeds 51 million, with the majority of residents (70%) residing in rural areas [15].
We conducted a cross-sectional study using secondary data from the Myanmar Demographic and Health Survey 2015- 16 (MDHS 2015-16) and included all women and men aged  years that included in the survey.

Myanmar demographic and health survey 2015-16
The MDHS 2015-16 survey was conducted between December 2015 and July 2016 under the scientific and administrative supervision of the Ministry of Health. It is currently the first and most recent nationally representative survey to gather comprehensive data on demographic factors, socioeconomic status, and health indicators of women and men aged 15 to 49 years residing throughout the country. The survey employed a stratified two-stage cluster sampling design to ensure the representativeness of the collected data, achieving a response rate of 98%. In the first stage of sampling, the numbers and locations of clusters were estimated at the state or regional level, as well as in urban and rural areas. A total of 441 clusters were included in the survey. The second stage involved sampling a fixed number of 30 households from each cluster. All women aged 15 to 49 years residing in the selected households, as well as men aged 15 to 49 years in every second selected household, were interviewed.
Three sets of questionnaires (households, men, and women) were used as a data collection tool. The contents were aligned with other DHS surveys conducted worldwide, with some adjustments made to suit the specific local context. The final questionnaire used for data collection was translated from English to Burmese and underwent various steps including a pretest to ensure accuracy and clarity. Data validation was also carried out at different levels. Field supervision together with technical monitoring visits were conducted by the DHS authority. A total of 17,622 respondents (4,737 males and 12,885 females) were including in the survey and involved in the present study.

Variables
To assess the correct knowledge on mode of TB transmission, a new variable was created based on the following question.
Question: How does Tuberculosis spread from one person to another? In this study, the answer 'a' was considered as correct knowledge on the mode of transmission, while the responses 'b to f' were considered as misconceptions. The variable was coded as a binary variable: recoded as '1' if the participant answered 'yes' to option 'a' and 'no' to the other options, and '0' otherwise. Self-reported prevalence of TB was derived from the survey question "Have you ever been told by a doctor/nurse or other health workers that you have/had tuberculosis?" The independent variables included the respondent's completed age, gender, education level, region, place of residence, current marital status, occupation, and exposure to mass media. Regions were categorized based on their characteristics: delta and lowland (Ayeyawady, Yangon and Bago Regions, Mon and the Karen States), hilly (Kachin, Kayah, Chin and Shan States), coastal (Rakhine State and Tanintharyi Region) and plains (Magway, Mandalay, Sagaing Regions and Nay Pyi Taw Union Territory). Occupation was categorized as dependent (homemaker), agriculture work, manual labor, clerical/ sales/ services work and professional/ technical/ managerial work. Mass media exposure was recoded as 'yes' when participants had access to television, newspaper, or radio at least once a week.

Data management
The data analysis was conducted using STATA software (version 13, STATA Corp., College Station, TX, USA). Descriptive statistics for background characteristics were presented as frequencies and weighted percentages. The correct knowledge on TB transmission mode and self-reported prevalence of TB were assessed using proportions and corresponding 95% confidence intervals (CI). To identify determinants of correct knowledge on TB transmission and self-reported TB prevalence among general population, a multivariable logistic regression model was utilized. We controlled respondent's completed age, gender, education level, region, place of residence, current marital status, occupation, and exposure to mass media in the adjusted model. Before including variables in the model, multicollinearity among them was assessed using the variance inflation factor to ensure their independence. Hosmer-Lemeshow goodness-of-fit test was performed to test for the model's goodness-of fit. The association between the included variables and the outcome variables was summarized using Adjusted Odds Ratios (aOR) and their corresponding 95% CI. To account for the two-stage stratified cluster sampling design, weight factors and the 'svyset' command were applied in all analyses. A p-value of <0.05 was considered statistically significant.

Ethics consideration
The original DHS survey in Myanmar was conducted following the necessary approvals from the Ministry of Health and obtained ethics approval from the Ethics Review Committee of Department of Medical Research. The use of secondary data in this study was granted by the DHS Program. The dataset provided for analysis was already de-identified and fully anonymized to ensure the privacy and confidentiality of the survey participants.

Background characteristics of the study respondents
The study included a total of 17,622 respondents, comprising 4,737 males and 12,885 females. Among the respondents, 41% fell within the age group of 35 to 49 years. The majority of the participants had attained at least a primary education level. In terms of regional distribution, approximately 44% resided in the delta and lowland region, followed by 33% in plain areas. The majority of the respondents (71%) lived in rural areas. About one-third (34%) of the participants had never been in a union. More than one-third (37%) were manual labour, and 37% were categorized in the two poorest quintiles. Two-thirds (69%) of the participants reported exposure to mass media (television, newspaper, or radio) at least once a week (Table 1).

Knowledge about TB transmission
Among the respondents, 64% of the respondents correctly identified the mode of TB transmission as "TB transmitted through the air when coughing or sneezing". (Table 2) However, less than half (44.6%, 95% CI: 43.9, 45.4) had the overall correct knowledge about TB transmission and misconceptions (Table 3).

Discussion
The present study reports the correct knowledge on TB transmission modes and self-reported TB prevalence among general population aged 15-49 years in Myanmar. Our analyses revealed a high self-reported TB prevalence while knowledge about TB transmission was low. Understanding and possessing accurate knowledge about TB transmission is crucial for both personal infection prevention and the prevention of transmission to others. In our study, less than half (45%) of the respondents correctly identified TB transmission through the air when coughing or sneezing without harboring any misconceptions. These findings align with a study conducted among factory workers in Myanmar, where half of the respondents correctly reported the mode of TB transmission [13]. Moreover, our findings are comparable with the similar studies conducted in other TB high burden countries in the region with 30% in India and 42% in Bangladesh respectively [11,16]. In our study, we observed that the older age group had a better understanding of TB transmission modes compared to the late adolescent group, which is consistent with studies conducted in Malawi and India [12,17,18]. This finding can be attributed to the accumulation of life experiences and exposures among older individuals, which likely contributes to their improved knowledge and behaviors related to the disease. Moreover, our study found that females had better knowledge of TB transmission modes compared to males. This finding aligns with a study conducted in Pakistan [4] but differs from studies conducted in India and Bangladesh [11,16]. The variation in results could be attributed to various factors, such as

PLOS ONE
Determinants of knowledge on tuberculosis transmission and self-reported tuberculosis prevalence in Myanmar Our study also revealed that individuals with a higher level of education were more likely to possess correct knowledge about TB transmission. These findings are consistent with previous studies conducted in various Asian and African countries [4,11,16,19]. The impact of school health education programs on improving knowledge and behaviors related to infectious diseases has been well-documented [20]. Education plays a significant role in providing access to information that is typically included in curricula and academic activities, leading to a better understanding of TB, including its transmission modes. Furthermore, education facilitates access to diverse sources of information and enables individuals to comprehend more complex messages effectively. Therefore, it is essential to strengthen school health education programs and peer interventions to enhance TB knowledge among late adolescents. In 2017, the Ministry of Health implemented standardized health messages in the local language for basic health staff. Leveraging these resources, health promotion activities at the community level should be specifically targeted towards late adolescents and socioeconomically disadvantaged individuals with no formal education.
Our study found that wealth was another influential factor affecting the correct knowledge of TB transmission which in line with studies from Africa and India [11,19]. Individuals from the poorest quintiles often face challenges in accessing or learning health information due to their need to prioritize daily work and livelihood activities.
Our study revealed that residents in delta and lowland and plain regions had a higher likelihood of possessing knowledge about TB transmission compared to those residing in hilly regions. This finding can be attributed to the challenges faced by residents in hilly regions in terms of access to healthcare providers and health education. The difficult terrain and limited infrastructure in hilly areas often make it challenging for healthcare providers to reach these communities and deliver health education effectively. In contrast, urban residents were more likely to possess correct knowledge about TB transmission which is consistent with studies from Bangladesh [10] and India [11,17]. Urban residents generally have better opportunities to access health education programs, which can contribute to their improved knowledge about TB transmission.
Our study findings align with previous studies [21][22][23] indicating that exposure to mass media had higher chance of having knowledge about TB transmission. Mass media plays a crucial role in delivering health messages to the general population. Therefore, it is essential to ensure that health messages delivered through mass media are accessible to diverse populations, particularly to those disadvantaged population. Our findings emphasize the need for focused educational initiatives and awareness campaigns to address aimed at bridging the knowledge gaps regarding TB knowledge among general population in Myanmar. The Ministry of Health in Myanmar in collaboration with non-governmental organizations (NGOs) and community-based organizations is employing a multifaceted approach to raise awareness about TB. The township health departments play a pivotal role as focal units for disease control activities including TB. Various awareness-raising initiatives have been implemented, such as TB campaigns conducted at the township and district levels, health talks and interviews on the radio, and health education activities in schools and other remote settings. The basic health staff actively engage in community health education by providing information to both the community and the family members of TB patients. These efforts are carried out in collaboration with the HIV program and the non-communicable disease program, focusing on diabetes mellitus. Furthermore, the integrated community malaria volunteers (ICMV) across the country have received training in infectious diseases, including TB, enabling them to effectively disseminate health messages within their respective communities [24].
The prevalence of self-reported TB in our analysis (2600 per 100,000) was high because the participants were asked if they have ever been infected with TB in their lifetime. Therefore, the result is not comparable with the finding from the fourth national tuberculosis survey conducted in 2017-2018 with 468 per 100,000 [3]. Furthermore, in the fourth national tuberculosis survey, TB prevalence was determined through screening procedures for bacteriologically confirmed pulmonary TB, whereas our study relied on self-reporting using a questionnaire. The fourth national tuberculosis survey reported that of who reported having a cough for more than two weeks, only half of them (54%) sought care for their symptoms [3]. This highlights the importance of promoting awareness about TB and encouraging individuals with symptoms to seek timely healthcare especially in TB high-burden country like Myanmar. Several studies conducted in Myanmar reported that private sectors including general practitioners and pharmacies were the first point of contact for TB cases for treatment seeking indicating the importance of public-private mix (PPM) in Myanmar [3,25,26].
In our study, we observed a higher reporting of TB among the older age group compared to the late adolescent group, as well as a higher prevalence among males. These findings are consistent with the report by the Ministry of Health [27]. Furthermore, similar finding was observed in the international literatures [28][29][30][31]. Older individuals may have weaker immune response system compared to younger age group making them more susceptible to TB infection. Males are more likely to work in occupation that involves outdoor or manual labour, which may expose them to the environment where TB is more prevalent. Moreover, males are more likely to engage in risk behaviors such as smoking or substance abuse, which may increase the risk of TB infection. Place of residence is not associated with self-reported TB prevalence in our study. However, the impact of urbanization on TB transmitted is well documented and the risk of TB transmission increases in the crowded urban areas [32,33]. The population density and inadequate housing conditions contributes to the higher prevalence of TB in these settings.
The Ministry of Health in Myanmar has undertaken efforts to provide high-quality TB prevention and care services to the population with the aim of reducing the prevalence of TB. The national strategic plan for tuberculosis is in alignment with the WHO End TB Strategy. To effectively identify TB cases, active case finding modalities are employed based on risk groups and settings using mobile teams. Moreover, the Community-based TB Care Program is performing services including screening among presumptive TB patients, referral to township TB centers for diagnosis and treatment, and provision of directly observed treatment (DOT) services to TB patients at the community level [24].
Our study has certain strengths and limitations. Our study provides national-level prevalence estimates for self-reported TB and knowledge about TB transmission. The data were obtained from a large representative sample of men and women, which enhances the generalizability of our findings to the wider population in Myanmar. Moreover, to ensure data quality, rigorous measures such as double data entry and validation were implemented. However, there are certain limitations to our study. Firstly, the DHS questionnaire primarily focused on assessing knowledge about modes of TB transmission, without gathering information about TB symptoms and treatment availability. While the interviewers were well-trained to ask the knowledge questions, the absence of comprehensive information on TB symptoms and treatment limits our understanding of the overall knowledge and awareness of TB in the population. The TB prevalence in this study was self-reported without confirmation through laboratory tests, and the survey questions were not specific to distinguishing pulmonary and extra-pulmonary cases. Moreover, extra-pulmonary TB is not widely known by the community. Therefore, there is a potential for both underestimation and overestimation of the actual TB prevalence. Furthermore, participants might have had difficulty accurately recalling past TB infections or symptoms, leading to recall bias. Additionally, the cross-sectional design of our study prevents us from establishing causality or assessing temporal relationships. Despite these limitations, we believe that our study provides valuable insights into TB transmission knowledge and self-reported prevalence in Myanmar. The data collected through the DHS survey, combined with the robust sampling methods employed, contribute to a better understanding of the current situation and highlight areas that require targeted interventions for TB prevention and control.